Linden Oaks Surgery Center
10 Hagen Dr., Rochester, NY 14625
Phone: 585-267-8200 Fax: 585-267-8261
AUTHORIZATION/CONSENT FOR SURGICAL PROCEDURE
I hereby authorize Dr. ____________________and whomever he/she may designate as their assistants, who are referred
to as “the Doctor” in the rest of this Consent Form, to perform the following surgical procedures:
For the following conditions:
1. The doctor has explained the condition and the surgical procedure to me. He/she has explained the purpose of the
surgical procedure and alternate ways of treating the condition.
2. In addition to the usual risks of these surgical or medical procedures, I have been made aware of certain risks and
consequences that are associated with the procedure(s). These include but are not limited to: Bleeding, infection,
numbness, stiffness, etc.
3. I understand that the explanation of the risks and consequences received is not exhaustive and that other, more
remote risks and consequences may arise. I have been advised that these more remote risks and consequences
will be explained to me upon request.
4. I understand that during the surgical procedure, the Doctor may discover a condition that he/she did not know
about or was not recognized before the procedure started. Therefore, I authorize the Doctor or his/her assistants to
perform any additional or different procedures in accordance with the Doctor’s professional judgment that are
necessary or advisable while this surgical procedure is being performed.
5. At the discretion of the doctor, I consent to the presence of manufacturer’s representatives to aid in the service and
correct calibration of the instrumentation. I understand that at no time will these representatives actively
participate in my procedure.
6. I consent to the administration of anesthesia (local, regional, MAC, moderate (conscious) sedation or general
anesthesia, etc.) by a Physician or Certified Registered Nurse Anesthetist as deemed most appropriate for the
surgical procedure to be performed. The anesthesiologist (or CRNA) will discuss details regarding risks and
alternatives appropriate for the procedure(s).
7. I consent to the administration of medications that may be necessary or advisable before, during or after the
procedure(s).
8. I understand the Doctor may have assistants participate with him/her or under his/her supervision in this surgical
procedure and related care.
9. I hereby authorize Linden Oaks Surgery Center to dispose of or send for pathology examination any tissue or
organs removed as a result of the procedure authorized above, or to preserve such tissues or organs, in its
direction, for scientific or teaching purposes.
10. I understand that a videotape and/or photo may be made of the procedure and consent to this providing my right
to privacy is protected.
11. I acknowledge that no guarantees have been made to me about the result of the medical/surgical procedure.
I have read this form in its entirety and that I fully understand what it means.
Patient Signature
Print Name
Date
Parent/Legal Guardian Signature
Date
MD Signature
Date